Dr Osman Bashir discusses the challenges and limitations of treating tattoos with laser technology
Lasers have been relied upon for cosmetic purposes since the 1960s.1 Now, not only have there been significant advancements meaning that procedures are often both safer and more effective, but there is a greater demand than ever before for treatment. Laser advancements have continued to accelerate, meaning achievable results are now varied. Whilst lasers can be used for many aesthetic indications, one of the lesser known – but emerging – treatments is tattoo removal.1
Treatment options for tattoo removal besides lasers are surgery, radiofrequency, infrared light, cryotherapy, dermabrasion and salabrasion. Unfortunately, none of these procedures are associated with satisfactory cosmetic results due to adverse effects such as scarring and dyspigmentation.2
Laser treatments for tattoo removal are often considered to be safer than other methods such as surgical removal and dermabrasion.2 This is because they are minimally invasive and are only used on the ink of the tattoos. In my professional opionion, lasers represent the modern standard for tattoo removal. Nevertheless, cosmetic tattoo removal does not come without its challenges. Tattoo removal is often performed in the proximity of ‘sensitive’ areas. The ink used in cosmetic tattoos may also contain substances that are not standardised and its colour therefore may change at a high temperature, so it's important for practitioners to be aware of the techniques and methods necessary to carry out the procedure in the most effective way for the patient.3
How does laser work for tattoo removal?
When the ink particles absorb the laser light, they are broken down into fragments, which are then absorbed and excreted by the body’s immune system. This process usually takes a few weeks. The larger the tattoo, the more sessions required to break up the ink particles.4 In my own experience, I would suggest that these can take up to an average of six to eight sessions. Colours that respond best to laser removal are black, red, brown, orange and yellow, while the most difficult colours to remove are blue, green and purple as they require a 694 nm wavelength. For red, orange, yellow and brown, a wavelength of 532 nm is suggested, while for black and blue, 1064 nm is required.4
Challenges and limitations
Although lasers have been the criterion standard for tattoo removal, selecting the best modality can be challenging because of the varying efficacies and adverse effects.5 One of the biggest challenges is that it is often difficult to predict treatment outcomes, and it is recommended to pre-treat small test spots to see how the patient will react.
Another challenge comes with managing patient expectations, as I have found that many patients often have unrealistic expectations. For instance, removal of large tattoos may need to be split up between two sessions and may take more sessions and time. Informed consent and dialogue between the patient and the laser surgeon before and during a treatment course is important since the patient needs to know the risk that removal can be unsuccessful, with complications including potential disfigurement.5
Choosing the right laser
The type of laser and wavelength chosen for removal largely depends on the patient’s tattoo colour and skin type. However, the Q-switched (QS) lasers are preferable, and I do consider this to be the most effective device for tattoo removal.
There are a number of types of FDA approved devices for tattoo removal; namely, the Q-switched alexandrite, Q-switched Nd:YAG and Q-switched ruby lasers. Considerable differences among the three have been reported in relation to the rate of clearing of the tattoo ink particles, tissue effects, beam profile, wound healing and side effects.1 There are new picosecond lasers using 432, 694nm and 755nm as well. Different wavelengths target different pigments, for example: 532 nm - red, orange, yellow, brown, 694 nm – black, blue, green, 755 nm - black, blue, green, 1064 nm – black, blue.
Q-switched 1064 nm/532 nm Nd:YAG Lasers like Hollywood Spectra from Lutronic are my preference, as they present important characteristics which can contribute toward the removal of tattoos, such as the ability to reach only specific targets with minimal damage to the tissue. Allergy can be localised, or at a distant site, due to an immunological response. The Nd:YAG also carries less risk of hypopigmentation which is hugely beneficial.6,7
An accurate preoperative assessment must always be performed, taking into account both the patient and tattoo characteristics.
I always check what type of tattoo was performed (was it professional, traumatic), the duration, depth, surface area, allergic reactions, if layered (double tattoos) and if they have tried any non-laser methods previously. We also ask if the patient is HIV, Hepatitis B or C positive; if they have any medical issues and a general health questionnaire is filled prior to laser treatment. Other factors to consider when evaluating tattoos for removal are location, age and the skin type of the patient. We always take photographs during each session to track progress and ensure that the patient will achieve a positive outcome.
Patients who would not be suitable for treatment tend to be those who develop an allergic reaction to tattoos, so we would avoid treating these patients. Women who are pregnant and breastfeeding are also unsuitable for treatment.
While adverse events are mild and often represented by erythema, laser tattoo removal does come with an increased risk of infection or permanent scarring and hypopigmentation. Practitioners can minimise the risk by taking an in-depth history from the patient, examining the colours within the tattoo in great detail and studying the results after each session. I would also recommend starting at a lower wavelength and advising the patients to apply a steroid, antibiotic cream after each treatment for two days.
Patients with Fitzpatrick IV-VI skin types should be treated cautiously due to increased risk of hypopigmentation following treatment. Lasers that penetrate deeper into the dermis, such as the Nd: YAG 1064 nm laser, are associated with a decreased risk of epidermal damage and hyperpigmentation.8
It’s also important to remember that some tattoo inks are resistant to laser, and multiple sessions and multiple wavelengths may be required for its complete removal. At present, there are no alternative methods that I would personally recommend for the removal of tattoos.
Tattoos are gathering increasing attention in the young population, especially in the second to fourth decade of life. With such trends, the rate of removal has also increased significantly. While also associated with some limitations – some tattoo inks are resistant to laser, and multiple sessions and multiple wavelengths may be required for complete removal – laser treatment with a Q-Switched laser represents the gold standard for tattoo removal.
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